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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 6781 Permit No.77�U <br /> APPLICATION FOR 1.WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> . (Complete In Triplicate)_ <br /> Application is hereby made to -the San Joaquin Local Health <br /> Distmade ,in�compliancetwithnSanuJoaquin <br /> and/or. install the work herein described. This appl <br /> County Ordinance No. 1862 and the .Rules and ,Regul.ations ,of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION/ <br /> Y Phone <br /> owner's Name r✓ <br /> city S <h v <br /> Address <br /> .. ,icense jgtf . Phone <br /> Contractor's Name v t <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/�/ RECONDITION_ / DESTRUCTION /_T <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other ''/ / <br /> DISTANCE TO NEAREST,.: SEPTIC TANK /�'' -t SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cagle Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing (n <br /> �t,f--Domestic/private I <br /> Domestic/publ ,C Driven Gauge of Casing <br /> Irrigation`"' . I Gravel Pack Depth of Grout Seal <br /> Type -of Grout <br /> Cathodic Protection Rotary <br /> Disposal �` 1 Other � Other Information <br /> Surface Seal Installed By:_ <br /> -Geophysical., <br /> PUMP INSTALLATION. L Contractor RS H.P. <br /> Type iof Pump <br /> PUMP REPLACEMENT: State Work Done � <br /> ` <br /> PUMP .REPAIRState Work Done <br /> i :. / / � - <br /> DESTRUCTION OF WELL: Well `Diameter <br /> ---�-_. -- - - -.Xpproximate Depth <br /> Describe Material and Procedure <br /> lth <br /> I hereby agree to comply with all laws and regulations owllthe <br /> construcion.LoWithrinaFIFTEENDistrict <br /> DAYS <br /> I and the State of California pertaining to or regulatinge <br /> after completion of my work on a new wellfurnish the San Joaquin Local Health District <br /> , I will fura <br /> F WELL DRILLERS REPORT of the well and notify them before putting the well in use. . The above <br /> 'knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> information is true to the best of my <br /> _. <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. TITLE <br /> SIGNED (DRAW PLOT FLAN ON REVERSE SI <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p I/FTNAL INSPECTION <br /> i p GROUT INSPECTION <br /> INSPECTION BY DATE _ -' ���7 INSPECTION BY <br /> C4 <br /> 6/77 M <br /> V u 11.96 Rau- 1-74 <br />